All right guys, I'm sorry to interrupt your lunch. We want to just keep moving so that we can end in a reasonable time. My name is Bergen. I'm a pediatrician at UCLA, a general pediatrician. I'm not a developmental behavioral pediatrician, so that's like my first disclaimer.
Three other apologies for you up front. One apology is that these talks that you're about to hear, basically from now on, are things that we've already done at previous trainings. So if you've already seen them, or you already know this stuff, you can come help teach it. You can leave.
I won't take it personally. Second is that in the middle section, I'm going to go through some information. In about 45 minutes, that used to be three hours.
So it's like three sessions that I've condensed down into one. And so it's a lot of information that's going to be kind of rushed. Again, it's all stuff that we've done in the past. But if you have questions, please stop me. Please slow us down.
We may not get through everything, but we can go through more detail if you need it. So please just let it be interactive. Feel free to raise your hands. And then the third apology is that... We were going to have these screening tool session workshops, and Paul Chung was going to do one of our sessions, but he had to leave because his daughter is sick.
And so we're going to sort of improvise and have three instead of four. And so Rebecca Dudowitz, who's brilliant and awesome, has kindly volunteered to do the work that Paul was going to do. So she's going to have a little bit of extra stuff.
And also, the other thing I was going to say, Pam. knows the developmental screening, the general developmental screening I was going to do with the Peds and the MTAT. She does it every day, so she can help do that too if we need.
So we'll be flexible. So, awesome. Thank you.
Please keep eating. Get up. Go to the bathroom.
Get more food. Get drinks. Whatever you need to do.
Is my mic okay? I can hear a little bit of feedback. It won't speak too loudly.
Okay. So, developmental milestones. This is a lecture that our well-known...
medical educator Lee Miller did for our medical students at UCLA. And then Kate Perkins did it after him. And now I'm co-opting their talk. So again, a fourth apology, fifth apology. But I will do the best I can to get through those milestones.
These are very basic. You probably know a lot of them, but it's kind of fun to review. And it's going to be interactive. So please feel free to get up and move around with me. What are the domains of development?
We think about what are the kinds of areas that we track. Social, I heard. That's not good.
So social, I heard language. Motor. That's right.
And so motor, we have what kinds? We have... Gross motor. And what about language?
Are there different kinds? How do we break that into subdomains? Expressive and receptive, exactly. So expressive are the things that come out of kids'mouths, the things they say, the sounds and language they produce. And then receptive.
And we'll talk about some of these things, because actually expressive language isn't all verbal. You can express and communicate and have a language-based gesture, say, that's actually very important to monitor. Good. So for the sake of this talk, we usually do gross motor first. We abbreviate GM.
So a baby, a newborn baby, what do they do? They're not moving around much. What can they do?
They cry, yes. Good. What are the functions of a newborn baby? They sleep, they eat, they pee, they poo, and they have to breathe to stay alive, right? They have to breathe in and out.
And a lot of those functions are automatic, right? Their digestive system goes without them having to do anything about it. There's one gesture they do have to be able to make in order to be able to survive, and that is that they have to suck.
Sucking is actually a reflex. If you put something in their mouth, they'll suck on it. What you'll do in your newborn examer, you'll take a gloved hand, put your finger and feel their palate, make sure their palate's intact, they don't have any clefts or anything, and then you make sure they have a good suck reflex.
And that's great. What's another reflex that happens? You brush their... Rooting, right?
So you brush their cheek, and they move their head from side to side. So that's actually the first milestone. Newborn babies move their heads from side to side. And that's great because they need to be able to turn their head to the source of food.
They also need to be able to turn their head to the side so they can breathe, right? So you never put a baby on their belly to sleep, right? Back to sleep. We put them on their back to sleep.
But we do recommend putting babies on their... Tummy's for tummy time, right? And they need to be able to turn their head to breathe. And you only do that when they're awake and you're awake and you're watching them, right? But, okay, so side to side.
That's a newborn. When they're one month old, what can they start to do with their head? Sorry?
What can they, at one month, yep. Lift their head, yeah, that's the one thing they can do. Lift their head up.
So you put them on their belly, they can move their head to the side, and they can lift their head up. There's like the turtle coming out of their shell. Can you all do that? Do a little lift your head, okay.
Lift their head up, and kind of move it down, good. And then, two months. They lift their head up, what comes next? You think about their nervous system developing from head to toe.
And central to peripheral, that's kind of how it happens, right? Their brain is connected to their spinal cord, and then there are these nerves that go out to their periphery. And the myelination or the development of strength and function happens from sort of head to toe and central to peripheral. So if you think, okay, head, neck, what happens next is their shoulders come up, okay?
And then at three months, so shoulders. At three months, what's next? Head, shoulders. They get up, yep, they lift up their torso and they can get up on their elbows. Alright?
They have chest, they get up with their chest. Chest and elbows. And then by four months, by four months, most babies, if they've had enough time on their tummy, supervised and awake, as they should, they have their head, their neck.
their shoulders, their chest, they get up to be on their wrists, right? By four months. And if the baby's up there on their wrist, what do you think they can do next? Right, they can turn front to back. And so that's the classic.
So they're up on their wrists and they can roll over. And usually if they've had some time on their tummies, they roll front to back first because that's easier, right? They have their hands, they can push off.
Since we've done Back to Sleep in order to prevent SIDS, so Back to Sleep was a national campaign that started in 1994, it's actually somewhat changed or modified some of these milestones a little bit because babies are spending so much time on their backs. So how many of you have seen a baby with a flat head, a flat occiput? Because they're spending so much time on their backs.
And, you know, so back to sleep has been really important to prevent SIDS. But unfortunately, some of the collateral damage has been that babies are spending too much time on their back and not enough time kind of on their tummies and rolling around and doing all the things they're supposed to be doing. So there are some babies who will spend so much time on their backs and they get kind of motivated to roll over back to front first.
Or they'll be kind of delayed in rolling. So if they're not meeting some of these milestones, like, right on the day that they turn one month, two months, three months, four months, are you going to start calling regional center, get everybody up in arms? No, right?
This is all just kind of general ranges. But usually, developmentally, they'll roll front to back first and then back to front after that, about five months. But that's all kind of approximate, varies widely. By six months, what are babies doing, gross motor-wise? Sitting, yeah, mostly sitting, unsupported, that's great.
Sometimes kids will do what we call tripodding. Can anyone demonstrate a tripod? You sit and kind of, you're sitting like this and then you put your hands down to support. They're not, you know, maybe not completely independently sitting, but around six months is when you start to expect them to be able to sit. Perfect.
So what can babies do by about 12 months? What's the classic gross motor milestone? Walking. Walking by 12 months. And so what are the things to get into going from sitting to walking?
What's sort of the next stage of sitting, tripodding? Yes, they get kind of on hands and knees, do the cat-cow, and they can kind of at one point sort of start crawling. They'll start creeping or crawling.
So around seven to eight months. And again, this is widely variable. Do not freak out if a baby's not crawling at that stage. What happens next? At about 9 to 10, they're crawling.
They get up to a furniture. They try to pull themselves up to stand. That's right.
Right. Pull up to stand. And that's a good precursor to walking, right? Kate Perkins'lecture hours include this. A classic is a 9-to 10-month-old baby who has learned to pull the stand, and they get up in the middle of the night, and they pull the stand.
They stand up, and then they start screaming and screaming and screaming because they don't know how to get down. It's like this new milestone. Parents come in the middle of the night, there's baby alert, and then they can't get back to sleep because they can't get back down.
What happens after you can pull the stand before you walk? What's that? Cruising.
What's cruising? Holding while holding on to it, very good. So between around 11 months, 10 to 11 months. Cruising, perfect. And so you can see how this is a nice progression and this is why we describe these milestones because they happen sort of in sequence and it kind of makes sense.
They go from one thing to the next and it's like a logical progression. So okay, let's review. Drop your forks, do the milestone march, okay? Newborn.
Everyone be a newborn. Turn your head to the side to side. Good.
One month. Head up. Two months. Chest, shoulders up.
Three months. On your elbows. Four months. Wrists. Roll over.
Back to front to back. Then back to front. Sit up.
Good. Crawling. Pulled with Stan, crude, and then walk.
Yay, you've made it to one year. Awesome. Gross motor continuing.
So we have one year, two years, three years, four years, and five years. Okay, now we're going to forget the months for a second. So at one year, we said we would walk.
Then what starts to happen as you are a toddler exploring, what do those sort of 15 to 18 months to two years kids do? They find something they want to explore, they start to climb. So by two, so between one and two, you're going to start to climb.
And around two, kids can learn to go climb up and down stairs. Okay, so around 22 months they can go upstairs and around 24 to 25 months they can go downstairs. So that's a little bit later. And what kind of climbing is that on stairs? Do they have like mature climbing where they can go on one step?
No, how do they do it? One step at a time, right? Maybe holding on to something.
One step, two steps. They do a step. And then they get their feet together, okay? One step, two steps. So that's immature climbing.
And then when does that mature climbing happen where they can go one step at a time? Three, yeah. So up at three and down by four, okay?
And again, this is highly variable. Many kids will be doing this slightly before or after, but... Generally, it's easier to go up than down.
So you can just go generally up first. And they do one step at a time, completely independently, up at three, down at four. And then what are some other things at three?
So the three, you remember three is tri. You can ride a tricycle. Good.
And at four, look at my notes. What did Kate say? Hop on one foot.
You can make a four with your leg here. Hop on one foot, and then once you're able to hop on one foot, what can you do? Skip to school. At age five is when you start kindergarten.
Skip to school. All right. You got it. Anyone want to do it?
Does anyone want to stand up? Walking, climbing, just demonstrating the one step, the mature, immature. I won't make you do it.
Okay. Gross motor. That's good. So next we'll do fine motor. So when a baby's born, what are they doing with their hands?
Let's see. They got them in fists, yeah. So generally fine motor, we talk about things that they're doing with their tips of their fingers, their hands.
But when they're newborns, they're mostly, a lot of the time is spent with their hands in fists. And that's actually something to watch to make sure that in the first few months they kind of unfold and open up on their own. If you see an older infant with clenched fists, that can be a sign of high muscle tone, right?
So we don't want that. But when they're newborn, they have fists. So we talk about, in this lecture, their eyes, actually. That's like an old surrogate.
So when they're first born, they can move their eyes back and forth, sort of like their head. So they can start to fix on an object and track, okay, by about one month. They're able to move. side to side by one month and sort of moving past midline.
At birth, they're going to be able to fix. By one month, they start to track. By two months, they're going to be going up and down. Their eyes can go up and down in response to stimuli.
And by three months, they can go in a circular motion. So that's just before. And then by three months, their hand should be open.
So what are they starting to do? at four months with their hands. What do four month olds do? Yes, good.
You can start to bring their hands to midline. So you start to move to midline. What else do they do?
They start to put their hands in their mouths. They're starting to have more volitional control of their hands, right? They can move things to midline, they can put things in their mouths. Tons of four-month-old babies, parents of four-month-old babies come in saying, I know my child is teething now because they're putting their hands in their mouths and fooling all the time. It's just a developmental milestone.
It doesn't necessarily mean that they're teething at that point. It's possible, but it's a little bit early. What else do they do? If you had a four-month-old baby lying in a crib with a mobile, what might they do?
Batting at it, right? Reaching and batting at things. Batting, reaching and batting.
Good. So by six months, what can they do with their hands? What's that?
Yes, they can start to grasp. And how are they grasping things at six months? I'm a six-month-old baby. What's that called? rake raking grasp right they basically have their whole open hand and they can grab something they haven't yet been able to sort of move their fingers just a few at a time so they have this whole hand grip so they have a raking grasp what else and then once they grab something they were raking grasp in one hand they can transfer to another yep transferring And so, this is a key time actually to talk about safety.
What's a safety hazard of six month old babies when they can start doing this? Choking on things, right, because they, you know, when they can just put their hands in their mouths, unless you put something in their hands for them, they couldn't actually really get it. So now that they can grasp something, transfer it to another, and get it into their mouth, it's pretty easy for them to do that. Just think about talking about parents, talking about choking hazards. and lots of baby proofing, right?
Because they're getting close to being able to crawl in the next few months, right? They're gonna be more mobile, and they can get things in their mouth. So it's a really good time to talk about baby proofing your house, if not a little bit before that.
Good, and then by, say nine months, what's a good fine motor nine month skill? Yeah. Good, that's right. So we have, so by, certainly by 12 months. That grass goes from raking to becoming a mature pincer.
By 12 months you want to see a mature pincer, which is just two fingers, an index finger and a thumb. And in between that we have what's called an immature pincer, what does that look like? Yeah, so some of their fingers together, usually like two or three, so not just a fine, so it's hard to get like maybe something really small, but you can get something that's a little bit bigger.
So this is a time, immature pincer around nine months to a mature pincer by 12 months. So this is a time when we start to introduce sort of soft table foods, right? And they can start to feed themselves. They're Cheerios and things like that on their trays because they can start to pick things up and feed themselves.
What else can they do now that they're starting to be able to? move those fingers and differentiate fingers, something else they start to do is point. Yeah, somewhere in the zone, starting around nine months, you might see pointing. That's a really key developmental milestone, the magic of nine months. So we'll talk a little bit more in social and emotional and language, because pointing, if you think about pointing, it's a fine motor skill, but it's also...
can be a social skill, right? Because you see somebody else and you want to show them something, it can also be a language skill, right? It's something that you're trying to tell them something, but you don't have the word yet.
So it's really an important, important milestone. Pointing usually starts to happen around nine months. Great. And that's it for fine motor.
We forget about it after that. You do start to have... It's important after that to be... providing kids with opportunities to develop fine motor. So in preschools, we have Play-Doh.
We have paper you can tear. We start to have safety scissors and pens and crayons and all these things so they can start to develop those sort of preschool fine motor skills. But we're going to skip ahead in the sake of time and go to language. All right, what's a newborn? What's the newborn language?
Yeah, they cry. That's right. They're expressing themselves.
So newborns cry. And how about receptive? What do they do when they hear a sound? Yeah, they startle or they alert. Sometimes it just means a pause.
Like you can tell that they can hear it. It's really a test of their hearing, but it's the beginning of receptive language. They alert to sound.
They become more and more awake and alert. They're looking at faces. They're moving, starting to move their eyes. They alert to sound. It's important to notice those things, right?
And by about, let's say about by two months, what's the classic language, expressive language milestone? We're going to talk about it on social. Yes.
How do they start to talk? Pooing, yeah, like, ahhh, ooooh. It's actually quite amazing, and some babies will actually match your pitch. My husband's a musician, so when we have a baby, he'll go, hi, and the baby will go, ahhh, like on the same pitch, and they say, that's amazing, they're brilliant, geniuses, they're like, they have good spinal cords.
Pooing, right, and then... when they after they start to have those open bowels, ah, ooh, then they start to put their lips together, their tongues, they start to make those other sounds that are consonants, right? So what can they do?
They can say, ah, goo, ah, boo, da, fa. So by four months, it's this kind of in-between state called ah-gooing. That's exactly what it sounds like, ah-goo, ah-goo. It's like a comedy, starting to put the consonants in. And then by six months, more consonants.
Ma, ma, ma, ma, ba, ba, ba, ba, da, da, da, da, da. So it's like the long strings of consonants repeating, and that's called babbling, right? Perfect. And those get reinforced, right, depending on what language you're speaking and what culture you're in. If you say ma, ma, ma, ma, ma.
And there's a mother in the room, they're going to say, yeah, there's like this wonderful reinforcement. There's a daddy around, yes, I'm your daddy. So by nine months, they start to say, mama.
and dada, but generally it's not specific. And by 12 months, we have mama and dada specific, plus one other word. So by one year, you can have at least one other word other than mama or dada.
Right? It's intelligible. Is that all clear and consistent with what you know? Good. So then by two years, what's a good two-year milestone for language?
Putting words together, yes, word-to-word combinations. And there are kids who will start to put two words together way before that. But certainly by two years, you want to start seeing two-word combinations and at least about 50 words or more.
And again, some kids have way more than that, but you want that to be sort of a milestone that they at least can reach. And about how much of that language should be intelligible to a stranger? At least 50%, right?
So that's sort of a rule of thumb. Kind of double 24 months, you get about 50 words. You can put two words together. It's 50% intelligible.
So by three years... What are they doing? They're putting small sentences together.
So like three or four words together. Small sentences, small sentences, phrases. You know, at least three words.
You put three words together, you get a small sentence. And about how much would be intelligible to a stranger? 75%. Yeah, so majority doesn't have to be perfect. And again, this is highly variable.
There are some three-year-olds who are really advanced. You can understand everything they say. They're speaking in paragraphs.
But this is what you want, kind of a minimum. That 75% and putting phrases together. You want them to start using plurals.
So it's sort of learning some of the rules of language. It doesn't have to be perfect. And it's fun to actually to watch the sort of three-to four-year-olds. learning, say, English grammar because there are so many irregular things.
So they'll learn a pattern and they'll repeat it with the next thing. They'll conjugate a verb in the same way and it's an irregular. Like, I go to the store. Right?
You put an ed at the end. And that's really normal and typical. And they learn, kids learn by you modeling language.
They learn so much by just picking it up. So it's not something you have to necessarily be on top of and correct actively when they're just three or four. It's just the learning. they'll get it by modeling. By four years, they are starting to use more of a past tense.
And how much would be intelligible? 100%. So it's sort of two out of four, three out of four, four out of four, right? 100% intelligible to a stranger. And then by four years, they should be speaking in long-term.
And again, they're becoming more and more kind of aware of the rules of grammar. Great. All right.
What's next? Social. What does a newborn do? Cry.
That's the way they talk. It's the way they communicate. It's the way they get your attention.
What else do they do? They're very sensitive. They're very sensitive.
They're very sensitive. They're very sensitive. They're very sensitive. They're very sensitive.
They're very sensitive. They're very sensitive. They look at you. They look at your face. The mother, the baby, the father, the baby, whoever's holding that baby, they start to look.
They look. They gaze at your face. So it's like a... they look and they love to look at faces.
They're evolved. All these things are basically evolution, right? We talked about having to turn your head so that you can eat and you can breathe and we have these reflexes so that you can turn to a breath and suck on something that goes in your mouth. We talked about another thing, motor-wise, we have these grasping reflexes.
So if you're a little monkey, you can grab onto your mother's fur, you can grab onto a tree or something. All of these are basically evolved mechanisms so that we can stay with our tribe and survive and be connected to the people who are going to take care of us. So social development is all about bonding with the people who are going to meet those needs. So you love to look at faces, and you especially love to look at the faces that you know, your parents. So newborns, you look at these, what happens at about six weeks?
Six weeks to two months, yeah, they start to smile. So a social... That's such a wonderful, gratifying time, right? When they're the two-month-old who's smiling and cooing. It's like those two months of investment where you're just sort of putting money in a well and getting nothing back.
You're finally getting some stuff back. It's really wonderful and gratifying. What do you say when somebody says, oh, my baby smiled in the delivery room the minute they were born?
You say they're a genius? Little Einstein? No, yeah, it's gas.
I mean, babies do smile because they have those muscles, and they'll be in their sleep, and they'll smile. They'll have gas. They'll smile, but it's not really a social smile in response to something pleasurable or a face until about six weeks. Good.
What's next? So by about three months, babies really recognize. and prefer their parents. Okay, and they can really distinguish between strangers and parents, and people that they know and don't know.
And then we're gonna skip all the way ahead to the nine to 10 months. What happens in that magical zone? What? Oh yeah, about four months, three to four months, three to four months is laughing. That's great.
That's also part of language I didn't talk about. Yeah, separation. So nine to ten months, they're really starting to have stranger anxiety. They go from recognizing their parents to really saying, I want to be with my parents all the time. I have anxiety around strangers.
They'll cry when the parent leaves the room. Otherwise, little babies can be passed from person to person. They'll smile at anyone.
By nine to ten months, they start to see. Stranger anxiety. And they'll also, we talked about this with fine motor, they like to start pointing.
So that's a social language, social and communication. And it's all kind of around this idea that by nine months you have object permanence, right? Have you heard about that?
Piaget. When your parent leaves the room, you know they still exist in the world. It happens somewhere between six and nine months.
You start to... know when something's not in your sight, it still exists. So you start to look for that object that falls off the high chair tray. The same thing with parents and stranger anxiety.
You know that your parents still exist. They're just not in front of you, so you're anxious. And then by about 12 to 15 months, this is all the magical time around your social and language being linked.
So you start to point. And you start to have what we call joint attention, which is really important, and we'll talk about why it's important in terms of our developmental problems. But between 12 and 15 months, you start to have something called social referencing, too, sort of related to joint attention. Does anyone know what that is? Can you describe it?
Like, if you're with a caretaker and the baby and you look somewhere, then you'll kind of... look as a child, a toddler, you'll look and see what your caretaker's seeing and what they're, so you're trying to see what they're seeing and point to the thing and make sure that you're looking at the same thing. And that's part of language development.
Why? If you're looking at the same thing and they say, that's a ball, then you start to associate what you're both seeing and what you're hearing with that's a word, right? That's a ball. If your mom's pointing to the ball and saying, that's a ball, and you're looking at a light. you're not going to get the correct object-word association.
So this is really important, the joint attention and social referencing as part of language development. Good. And then toddlers.
So I'm going to say sort of 18 months to 2 years, 15 months really to 2 years, and we're going to sort of skip ahead and go to the videos now. But it's really a key developmental point. And I think that you're going to talk about it a little bit, Rebecca, in your parenting.
and sort of how to manage toddlerhood. But in terms of social development, it's an amazing time of sort of push and pull. So a toddler's job in the world is to explore.
They're little explorers, and they're going to run around and explore and do everything. They would have this drive for independence, but they also don't have all the skills they need to be independent, right? So it's this kind of push-pull. They'll, like, run away from their parents and then realize they're far away from their parents and kind of freak out and be like, Oh, no, where are my parents? Have you seen that, like, in an airport?
Have you seen that in a toddler? Running gleefully and then realizing they don't know anyone around them and they freak out. Or they're running around, but they can also fall off a cliff, right? You're really worried that they don't quite have the coordination to be independent.
They also want to be independent, but they don't have the language skills to be independent. So you start to see things like temper tantrums, right? They want to do these things all by my big self, but they can't quite get it. They can't quite dress themselves. They can't quite do it all independently.
So it's a really wonderful time, and Rebecca's going to talk about that a little bit in terms of how to manage. some of the typical behaviors that come up during that time. And I'm going to talk a little bit after the videos about some of the things to look out for. Okay, when is this not normal?
When do we have the delays, developmental problems like autism, things like that that are going to disrupt normal development? Okay, good. So let's look at a video.
Okay, get your clickers ready. Now, what do I have to do to start the video? Here we go. Here we go.
Come on. Come on. Come on.
Come on. How old is this baby? What do you think?
Put in your best? Any more? Speak now or forever hold your peace.
All right. Good. The majority of you said nine months. That is the correct answer. A nine-month-old baby.
What tells you this is a nine-month-old baby? What are they doing? Crawling, sort of creeping.
Creeping is like sort of crawling, just scooting yourself along or crawling. creeping without actually doing the coordinated arm and leg but this baby's basically crawling good let's go to the next one just for the sake of time Crying. Follow that baby, put in your best answer. All right. Yeah, good.
Most of you said newborn. That's the correct answer. 30% of you said one month old. How do we distinguish between a newborn and a one month old in this video?
What's the big clue? The head. Yeah, the baby has really bad head.
It's not really moving their head at all. Remember, at one month, they can start to sort of move their head up and down. So one way to test that is to do a head lag, which is what that examiner did.
It was to pull up their arms. and they basically have no neck strength or function. They're really not.
All they're doing is crying. Okay. Just two more, and then we're going to move on.
Duck. Duck. Okay, so that's not a lot of time to really see that baby, but what do you think is your best bet? All right.
Good. Most of you got it. Two months.
So we know it's not a newborn because that's the difference between the newborn video and this one. They really, the head lag went away, right? They did the same maneuver and this head came with them.
But why is he not four months? He's still just kind of not super, like his trunk control, he's still kind of floppy, right? He's not necessarily bringing his hands to the midline yet. He's just kind of cooing in terms of language. So yeah, not yet four months old.
Certainly not rolling. Couldn't imagine this baby rolling yet. Come on. La la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la la I see this paper.
Is it pulling off? Are you putting in responses? Huh, okay. Sorry, the pulling didn't work on that one.
Six months, right? That's what you all say. Sorry about that. The pulling wasn't working, but yeah, the baby is sitting up, starting to babble, going, ba-ma-ma-ma-da-da-da-da.
We didn't talk a little bit about jargoning. That was something I kind of skipped. But acting as if it's language when it's totally nonsense, right?
So going, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah. It sounds like they're asking you a question. That's sort of like before you start having recognizable words around a year, you'll start to hear a lot of jargoning as they're sort of preparing to speak. And then as they start to get more and more single words in that first year, second year of life, they'll start to have words. spattered in there like mama mama mama milk like I just asked my mommy for a glass of milk but you just the only word you could understand there was milk that's called mature jargoning so this is babbling though that's way before that mama mama and you can see how it was being reinforced by the parent there dada you mean dada um good and it was slung strings of babbling instead of saying mama or dada All right.
So actually the answer to this one is 24 months, but I agree with you. I can see why you would say 18 months for this one. So this is like sort of a trick question. So this baby is running.
That's a good 18-month skill there. Souping and recovering. Usually 18 months can soup and recover.
Her language is actually, she's not really saying a lot of words, certainly not sort of putting words together, at least as far as you can see in the video. Who knows what she can do in the rest of her life? But, you know, maybe she has some speech delay.
But this is a 24-month-old kid, and she's climbing and throwing and doing all these things, but I can understand why you would say 18 months. So that sort of. Unfair.
And last one. Drinking from a sippy cup. Drinking from a sippy cup. Drinking from a sippy cup.
Drinking from a sippy cup. Drinking from a sippy cup. Drinking from a sippy cup.
Drinking from a sippy cup. Drinking from a sippy cup. Drinking from a sippy cup.
Drinking from a sippy cup. Drinking from a sippy cup. Drinking from a sippy cup.
Drinking from a sippy cup. Drinking from a sippy cup. Drinking from a sippy cup.
Drinking from a sippy cup. Drinking from a sippy cup. Drinking from a sippy cup. Drinking from a sippy cup.
Drinking from a sippy cup. Drinking from a sippy cup. Drinking from a sippy cup.
Drinking from a sippy cup. Hi! So you heard one word, hi, out of that baby. Say hi? Yeah, hi!
Well, you'd be the smartest. Hi. Say hi. Hi.
Hi. Hi. Hi. Hi. Hi.
Hi. Hi. Hi.
Hi. Hi. Hi. Hi.
Hi. Hi. Hi. Hi.
Good. So that's right. 16 months. Again, I think given the last one that was 24, it almost looks like 18. I can understand why some of you might have said 21. But this baby is also one word, saying hi, not a lot of other words, is doing some of the pulling up on things, drinking from a cup, following commands.
Good, sort of toddler, classic toddler. Perfect, you guys are great. Okay, so I'm going to move this because I have another mic.
So now we're going to talk briefly. Again, this is like three lectures combined into one, and this is a long section. So again, if you need to go take a break, feel free to go do that.
We're going to talk about when does development become abnormal. All right, what are the things you need to look out for? And as clinicians seeing kids in clinics, we're going to do... what we call screening, looking at all babies to see when you have a sign to try to detect early signs of developmental and behavioral problems.
So about 10% to 15% of kids, depending on the age, so of all kids age 3 to 17, there's a prevalence of 15%. That's the most recent data, and this is in terms of developmental and behavioral kinds of issues. This is based on the national...
health interview survey and they look at conditions like autism, intellectual disability, cerebral palsy, epilepsy, severe language disorders, hearing and vision impairment. So those are kind of all considered developmental disabilities. It's a big, encompassing, wide-encompassing term. If you think about birth to five, it's probably closer to 10% because they haven't had enough time to develop things like learning disabilities is not something you would necessarily expect in a preschooler, right?
You can have different expectations. But for the older kids into school age and adolescence, that's a 15%. So it's interesting and important. But then thinking about what kids are actually getting in terms of services, in young kids from birth to five, about 5% of children are actually getting services through our Individuals with Disabilities Education Act.
the IDEA services. So all of you know what those are. Part C, Part C. You know what those are?
So what's our Part C system here in California? Early intervention. Where would you send a child who you worried about developmental delays? To regional centers, right?
Yes. So our regional centers here in California, for the birth to three kids, are doing the Part C. And then after that, schools. Yay. So three and up.
It's going to be through Part B or special education systems. They're just sort of different pots of money, but all entitlement programs through the Americans with Disabilities Act. There's a bigger group of kids, probably 25% to 30% of kids, who have some concerns and risks that aren't going to be eligible for those high-level services. And then there's 60% to 70% of kids that are going to be typical, but you still want to do all that screening and promotion and monitor their growth and development. So really thinking about the whole pyramid from...
typical of the kids with disabilities and how do we assess that, look at them for early detection and provide appropriate early intervention. So again we talked about these domains, language is both receptive and expressive and so in expressive language it's not just what they're doing with their mouth, they're also doing things like pointing that can be considered part of expressive language. And then social-emotional, highly important and then motor.
And so again, we talked about this, but we talked about primotor and gross motor, and that was all of our domains and the milestones we saw. This is a terrible picture of my husband when he had really long hair. And our first baby when he was about nine months old. But what domain of development is this a demonstration of? There's social in there.
There's language, right? They're looking at the same direction, trying to communicate with each other. Joint attention, you can see joint attention, the magic nine month old.
What else? It's fine motor, right? Using their index finger to point, that's a fine motor skill. It's also gross motor, he's sitting up.
So these are things that are all entwined. It's not like you can really see one thing at a time. It's all, there's gross motor, fine motor, social, and language all wrapped up into this one gesture. So it's hard to really disentangle them, even though we try to break them down into milestones. So as a clinician, the recommendations are to do surveillance at every wellness visit.
So surveillance, can you describe what surveillance is, developmental surveillance? Who can you describe? Yeah, so asking questions, asking about development. What do you think?
How's it going? What can your baby do? Do you have any concerns? Those are just general questions to try to elicit parents'concerns and document any concerns that might arise.
But it's not actually screening until you're using a structured tool with questions in a form. Okay, so a developmental screening test. which we'll go through with some of those formal screens, the recommendation is to do that at nine months, the magical nine months, where you have joint attention and all sorts of motor milestones, 18 months and then 24 or 30 months. And then an autism-specific screening tool, which we'll learn how to use the M-Chat.
Rebecca's going to teach you how to do that at either 18 and 24 months. And then, again, if any of these don't happen by 18 or 24 months, doing them at 30 months is okay. It's sort of a catch-up. But these are the recommended ages. And then if there's a concern to respond promptly, take it seriously, make referrals as appropriate.
Okay. So it's good for us to be the people to do this in some ways because we see kids a lot, right, as a clinician in a clinical setting. They're coming in for well-due visits. But how many of you are not in clinical settings? Pam, you're sort of, like, affiliated with clinical settings, but you do a lot of screening.
In schools, in child cares, you have screening fairs where people come in. So there's other venues. But it's nice for clinicians to be able to do it because we do see most kids in the first three years of life.
And the professional recommendations are there for us to do it universally. But we know, just looking at the literature, looking at... The epidemiology, the clinicians are not necessarily doing as good of a job as we should.
There are kids getting missed. So there are kids with autism that may not get diagnosed until they come to school and they're having school failure, and you sort of think, what happened for those first five to six years of that kid's life? Why was this missed?
And it's complicated. Parents have denial. They don't want to go through with follow-up with referrals. It's not just like... failure of the clinical system, it's a failure of the entire system, but we know that there are kids getting this.
So thinking about the difference between surveillance and screening and surveillance is really this longitudinal, flexible, less formal where you're just kind of asking about concerns, but you have knowledge about the child's development and you're trying to track that child's process and try to identify any concerns. Versus screening is when you use a structured, validated screening tool at specific ages in order to identify. identify risk. And you do that for everyone. Screening means all comers, not something that you do because you're concerned about a problem.
That's getting more into diagnosis and assessment. Screening is when you do it for everyone even if they don't have any outward signs. Good.
So I'm just going to skip through this quickly, just asking about parents'concerns, keeping records of it. identifying risk and protective factors. And then we know that policies can change this.
So in Massachusetts, there was a law requiring developmental screening. So it's not just a recommendation in Massachusetts, it's a law requiring, because there was a case of a mental health condition in an adolescent, I think, and the parents actually sued the state and said, why did you not discover this sooner? And so there was like a court order, so all pediatricians have to administer its formal screening tool at all well-tell visits.
It's almost like too much, above and beyond the AAP recommendations, but when you make it law, you can get the rates up. Still not at 100%, but they're doing better than the rest of us. You can see North Carolina has made really good statewide efforts to increase screening and referrals, so they have above 50%, but the rest of us in California, they're somewhat below average, but we're about 30%, so not great.
So when do we call it a delay? We went through this milestone lecture as if things happen on a schedule, and it's not really a schedule, right? So if you see a kid who's four months old and they're not yet rolling over, are you going to say you have a developmental delay?
Not necessarily. You want to see in the context of all the developmental stages that happened before and where they're going after that. You see their trajectory.
But once a kid gets to about one or two years old, one and a half to two standard deviations below average. So two standard deviations below the mean is the bottom 2.5% of kids, right? So 95% of kids are going to be within two standard deviations around the mean.
If you think of a normal bell-shaped curve, and 2.5% on either tail. So if you think about just one tail, that's like a small proportion of kids. So that's actually a pretty stringent...
criteria, then you do call it a delay. And you describe the delay based on the domain. So if it's speech delay, you say speech, language.
If it's more than one, you can call it global developmental delay. And in the first five years of life, it's a prevalence of about 5% to 10% with boys being more prevalent than girls in terms of having delays. So this is an example of a screening tool. This black area is two standard deviations below the mean.
So that's why they do that. That's why they do that shading, is to look at how that child is in terms of other children that same age. That gray zone is one to two standard deviations below the mean. So that's something to be alert. It's not necessarily a delay, but if they're in that grade zone, it's like, okay, they're below one standard deviation or more below average, and then the white is one standard deviation below the mean or above.
We're going to talk about this when we do our screening workshops. So if you see a young child who you expect to be talking, and they're not yet talking, what could be going on? Maybe they can't hear.
What else? Yeah, maybe they're just not getting exposed to that language, so you're talking to them in English, they're not speaking to you in English. Could be, yeah, it could be an exposure. Anything else? What could be going on that the kid is not talking?
They could have trauma. Yeah, they could have PTSD, they could be traumatized, they could be severely anxious. What else? They could have autism. Yeah, so it's an environmental thing, so it's not, they're not needing to speak because somebody's getting them.
They're able to communicate through gestures, other things. Good, so just to think broadly, it could be about hearing, it could be about the way they actually move their tongues and their lips and their mouths. Autism spectrum often presents with language and speech delays. It could be neglect, just not being exposed.
It could be being abused. It could be PTSD going on. So thinking about this whole process as speech is something that you can measure, but it's actually just the tip of the iceberg.
It comes on this foundation of having a secure attachment with your caregiver, all that social and emotional stuff, and then joint attention, looking at the same place so that when I look at a ball and my baby looks at a ball and we're pointing to the ball, I say, ball, he hears that, he associates that. So it's a lot of different things. That's how it all builds.
So speech is just the tip of the iceberg. It's something that's easy to observe. And we know that there are socioeconomic differences in speech development, right?
So this is now famous, Hart and Risley, they actually recorded hours and hours and hours of actual natural language environment in different households. These are small samples, but they saw marked differences in the child's expressive vocabulary as early as 16 months with big gaps. happening between sort of among the different socioeconomic strata. And this is what's been called now the, what do we call it, the million-word gap, 50 million-word gap, how many thousands or millions of words it is at this point. But yes, the gaps in vocabulary probably related to amount of exposure that they're getting.
And so what is a treatment? So we then give them exposure to language-rich environments. You can teach parents. Direct strategies. What are things you can do to notice that your child is trying to communicate with you?
What can you do instead of just giving them what they're pointing to? You can encourage them to say the word, right? Because if you reward just the pointing and the grunting, then it gets rewarded, right? So you can teach parents direct strategies. You can have formal speech therapy with a speech and language therapist.
And then there are these entitlement programs. So the early intervention programs, part C from birth to free and then part B. or B, special education from 3. It's actually, that goes beyond 18. I think it's like 20, right? That's in there on my part.
So once you get to age 3, though, and you can actually reliably measure IQ, a developmental delay can be then diagnosed if it's bad enough as intellectual disability. That's just something to know that if you have tooth and aviation phlegm in an IQ test, It's a reliable IQ test. We call it intellectual disability. We no longer use the term mental retardation, but it means the same thing.
But it's not a term that we should be using because it's not as respectful of that individual and descriptive of their actual disability. The way we measure the severity of intellectual disability is through their adaptive functioning. How well can you actually function in your environment? So not so much about the actual number or the IQ.
but how well can they have relationships, hold a job, do tasks of daily living. So things that, can you think of any causes of intellectual disability? Mostly it's things we don't know, idiopathic means we don't know.
Can you think of any genetic causes or toxic exposure on the heels of our environmental talk? Lead, yeah, so maybe lead. Lead exposure in utero or mercury exposure in utero.
lead exposure early on in brain development, like, gosh, Flint, Michigan. Are we going to start to see some intellectual disability coming out of there from this early? I don't know.
It's too soon to tell. But certainly lead is one of the toxins. Mercury is another.
Any genetic conditions you can recall? Or other in utero exposures? Yeah, so there are some genetics in Down syndrome, some of the trisomy Down syndrome being the most common fragile X. Sex is another one that's a common genetic cause associated with intellectual disability. In terms of other toxic exposures or teratogens, so alcohol in utero, fetal alcohol syndrome, probably the number one preventable cause of intellectual disability is fetal alcohol.
Infections, things, again, often in utero, some of the like toxoplasmosis, CMV, EBB, those kinds of things in utero. And then trauma, what can happen that could cause an intellectual disability? Yeah, so perinatal, like hypoxic, ischemic, encephalopathy, lack of oxygen at some point, and then postnatal brain trauma, basically a traumatic brain injury early in development.
So this is what are we looking at here, the physical features associated with a syndrome. Fetal alcohol, yeah, so that's classically. It's hard.
There's no blood test or genetic test to diagnose fetal alcohol syndrome. You have to have a history of exposure, and then you have characteristic physical characteristics. So the flat, the smooth siltrum, the thin upper lip, sometimes micrognathia, microcephaly.
And then we're going to see things like Zika associated, you know, microcephaly and intellectual disability at some point. But, yes, this is something that happened in their brain development. So what we do is we test their intellect, we test their adaptive functioning, you want to rule out something like hearing impairment, consider all these kinds of causes, mostly just to see if you can take away any exposure, right? If there's anything that you can make better, but you don't necessarily need to do like a genetic test on everyone with intellectual disability.
And then they're basically behavioral, educational, supportive kinds of treatment. Good. So let's talk about autism.
Again, my apologies, this is like five different lectures, pooped into one, smushed into one. This was the old diagnostic and statistical manual, the diagnosis of autism. You had to have these three things, language impairment, social impairment, and repetitive or restrictive behaviors. And a couple of years ago, this statistical manual got revised, and now it's the DSM-5. And basically, the communication and the social domain just kind of went into one.
And they got... collapsed into one that's called social communication impairment. So a condition like Asperger's that used to not be considered part of the autism spectrum is now part of the autism spectrum, right?
So somebody with Asperger's could have a very high vocabulary. They don't have language impairment, but they have social communication impairment. Does that make sense? So it's that reciprocity, like understanding nonverbal cues, knowing who you're talking to, knowing your audience, having that back and forth. That's sort of more important than the actual number of words.
Good. So again, language and social development are linked. Babies are born staring at their mother's faces.
They start to have joint attention. And then when you're looking, this is at an aquarium, you look at the blue fish, you look at the red fish, you look at the shark. You learn those words because you have joint attention.
So that's really the thought in autism is that it's sort of a failure of joint attention that causes some of that language impairment. So here are the actual criteria, thinking about the reciprocity, the nonverbal communication, relationships, and then anything that's restrictive or repetitive. So things, stereotypes, things that babies are going to do again and again, like head banging, being really rigid about routines, like freaking out if you don't have exactly the same thing in the same way at the same time every day, being really restricted, having only fixated if you only are interested in like... red crayons and you can't move their attention to anything else, then that's a concern.
And then being hyper-reactive to sensory stimuli. So one of the questions on the M-chat you'll hear is... Are they really sensitive to loud noises? Which is something that we probably get some false positives, right?
Because a lot of babies or a lot of kids are going to be like, if there's a siren or there's a loud noise or there's a fire alarm, they're going to cover their ears, and that's kind of normal. But it's more extra sensitive, okay? And then it's a developmental. It's impairing your function.
And then the classification is really about how much support you need. So there is a rise in prevalence. This is...
Now, the CDC estimates 1 in 68 children to 1 in 42 boys, so much more common in boys. So it's really somewhere between 1 and 2 percent, but it's been going up. And why do you think it's been going up? Yeah, we're getting better at diagnosing.
There's raised awareness. Certainly people are trying to get it diagnosed earlier to get services and to be more aware, to do early detection, early interventions. But I think even beyond that, there's some...
feeling that there actually is a real increase in prevalence. So beyond just the better diagnosis, there probably is an increase, and maybe it's related to something. I don't know. What do you think, Sharam?
It's all speculative. We don't know. The best thing we know about autism is that people probably are genetically predisposed, but it's not like a 100% penetrance. It's like a predisposition, and there's something that triggers it. We just don't know what it really is.
Okay. Again, more in boys than girls, we should be screening. Tools like the MCHAT are good for screening, and then we have other tools to use to make a diagnosis. So a tool like the ADOS, which is the Autism Diagnostic Observation Schedule, or the Autism Diagnostic Interview, the ADI, are things to use to actually make a diagnosis. And then again, mostly behavioral treatments.
Applied Behavior Analysis, or ABA, has the highest. evidence of effectiveness, teaching things directly, teaching parents, teaching kids how to do social skills. And I'm just going to skip through this again in the interest of time. But basically, ABA is behavioral kind of analysis and training that can go from being very therapist directed. So discrete trial training is like, look at me.
Good, you looked at me. I give you this token treat. You have like an M&N every time you look at me. you train somebody to do something very small, very discreet, with a very clear reward at the end of it, versus something more like floor time, which is much more child-directed, where the therapist kind of follows the child around. But anything where there's a therapist, a child, they're trying to analyze those behaviors to be considered ABA.
All right, ADHD. Sharam, you want to come up here? This is, again, Sharam's lecture, condensed into 15 minutes. We're going to be talking about... The screening using the Vanderbilt, actually the Vanderbilt's probably not really a screening tool.
I should be consistent. It's more of a diagnostic tool. So we don't do it for everyone. We do it if you have concerns.
And you're going to be asking some of these questions about core symptoms. So the core symptoms are hyperactivity or impulsivity. Is that kid like run by a motor? They just can't sit still.
They're fidgeting. They're moving all around. Or are they being very inattentive, forgetful?
inattentive, not being able to pay attention. The subtypes of ADHD are hyperactive, inattentive, or combined, where they have both, both hyperactivity and inattention. And you want it to be in more than one setting. So if it's just happening at home, but they're perfect at school, there's probably something going on at home, right?
If they're perfect, if it's just happening at school, and nowhere else, there might be something going on in that class. The prevalence is about 11%. Again, males more than females.
Poor boys, gosh, they're getting all these things disproportionately. But as Sharon noted here, it's likely that females are probably underdiagnosed. And that could be because girls tend to have more inattention symptoms and less of the hyperactive symptoms, and so it's not as disruptive.
So if you're a teacher or a parent, they're not like running all around, they're just sort of losing things, being forgetful, and that's the disruptive symptoms are what people are responding to because it's disruptive to your life. So what are these symptoms of hyperactivity? These kids, it seems like they have a motor inside them, they're just always on the go. They can't sit still, they're constantly moving, tapping their feet, moving their fingers, they're squirming. They have really a hard time at work or at school or in a lecture sometime when they have to sit still.
Older kids can sometimes force themselves to do it but they feel really restless. So they've learned to be social, to sit still, but they just... are just not loving it and then having trouble playing quietly. So impulsivity is things like not being able to wait your turn, talking excessively, running out into the street, climbing and running inappropriately, interrupting, intruding, blurting out answers. And then inattention is when you're making really careless mistakes, you're having trouble paying attention, you may not be seeming to listen, even when somebody's really looking at you and trying to stay, they're kind of staring off into space.
not following through on things like homework or chores, difficulty organizing, losing things, being easily distracted and being forgetful. So these are all some of the symptoms you'll see on the screenings or on the diagnostic tools. So you do wanna do a comprehensive history and physical. You wanna find out whether this is happening in more than one setting, what are the actual symptoms?
You can ask those structured questions. But there are reasons why people might be dreaming, daydreaming. So if, say, you are having trouble learning and you're in a classroom and you have a reading disorder and somebody is asking you to read, you might have hyperactive or impulsive kinds of behaviors just as a way to get out of having to read. So you do want to rule out learning disorders.
You want to rule out things like depression or anxiety. So a very depressed or anxious kid might kind of withdraw. stare into space, but not because they're having trouble paying attention.
So you'll see in the tools how other symptoms of other kinds of mental health conditions are addressed to try to rule those things out. And then again, it has to be in at least two settings and using a standardized tool is recommended. So this is the Vanderbilt. You guys are going to do it in your groups.
You can give it to the teacher. You can give it to the parents. It's available in multiple languages.
We certainly use it in Spanish and in English. I don't know. other languages available in Spanish and English for sure.
And so the criteria for diagnosis, you have to have six or more of the symptoms. If you have six or more hyperactive symptoms, you're called hyperactive subtype. If you have six or more of the inattentive symptoms, you're called inattentive subtype. If you have six or more of both, you're combined.
If you're more than 17 years old, you only have to have five of the symptoms. And that's probably because, again, the older kids get, the more they've been socialized to try to sit still. So it's a little bit different in older kids and adults.
Again, it has to be actually interfering with your function in more than one setting. It has to be present before the age of 12. That's a new diagnostic. That's the DSM-5 criteria.
It used to say 7. We've gotten a little bit more liberal, which is a good thing, I think, because... There were a lot of kids that weren't really recognized before they had to really have high expectations in school. Again, it's in excess of the developmental level of the child. So thinking about that toddler whose job it is to explore, we don't call them having ADHD because they're not sitting still in a seat, right?
You don't expect an 18-month-old to be sitting still in a seat, right? If a two-year-old's running around, that's a good thing. That's their job. to develop and explore.
So it has to be sort of appropriate to their expectations. Good. Some other things that we want to think about and rule out, oppositional defiance, conduct disorder, depression, anxiety, learning disorders, and then absence seizures. Do you know what those are?
Yeah. Describe it. Kind of staring, yeah, like blank stares. It happens for very brief periods.
You can elicit it by hyperventilation. People actually do that. You get somebody to hyperventilate. You can get them to have an abdominal seizure. But it's something you do want to rule out.
And then medications and treatments. I'm going to skip through a lot of that, but maybe, Sharam, in your group, you can talk a little bit about medications if there's extra time. Going through the Vanderbilt by itself won't take too long.
But it's really good to do these things in combination. So medication is the hallmark, but it's... It's good also to make sure that you have good parenting, that you have structure in your life, you have routines, you have a cleared off homework table, you know when you're supposed to do your homework, you have a folder that has your homework in it, you have things that are going to help structure your life so that you don't have to worry about all these things.
For little kids, we try to do behavioral things as long as possible before getting right into medication. So preschool age kids, you don't want to jump to medications right away. But once kids are old enough and in school, Medication really is the primary management in addition to behavioral therapy.
Talk about this. Keeping everything in its place. And then some resources, so the NICHQ, the National Initiative for Children's Healthcare Quality publishes the Vanderbilt, it's free, it's online, you can Google it and print it out, we have it in your folders, but they have other things about guidelines, what to do if it's positive, and then things like the parent training, like incredible years, triple P. All right, so we don't have much time.
What is the most important thing that What's the difference between baby blues and postpartum depression? How many people in here have had a baby? Did you ever, in those first two weeks after you had that baby, cry? Maybe once?
It's like 80%. 80% of women who have babies cry at some point in those first two weeks. It's a hard time.
You're sleep-deprived. You've just had a baby. You're nervous.
Baby blues is really common. You have this expectation of having this perfect little baby, and they're crying, and breastfeeding is not going well. And so the difference is that it gets better. It improves.
within two weeks after delivery. Baby blues is very common, but if it's not getting better after those two weeks, then you need to be worried about postpartum depression. So our final screening tools are going to be depression screening that we can use perinatally.
This is our team. Kamala did these slides before, so you're a great little wow sister. So how was the miracle of your birthing experience, Hazel? It was six minutes, and it felt like I was being licked by kittens.
So I really like this thought that it's really like a perfect storm, right? So you have these hormonal things, fluctuations going up and down. You expect motherhood or parenthood to be like a Marie Cassatt painting where you're just still and gazing at each other.
You're not sleeping. You have a major change in your life and your family. So it's like these biopsychosocial things all at once.
It's this perfect storm. that creates postpartum depression. So especially in women who are predisposed, if they've had a personal history of depression or anxiety, they're much higher risk of having that be worsened or triggered by the perinatal experience. But the diagnosis is about two, anything within the first year of delivery is having two weeks of these.
I don't know if any of you have been to medical school or have learned the SIGGY-CAPS acronym. Sleep, interest, guilt, energy, concentration, appetite, psychomotor agitation. That's basically these symptoms, having them for more than two weeks and impairing your function.
It happens up to 25% of the time. That's a high estimate, but that's the highest estimate and that's certainly concerning. One in four women could have postpartum depression.
Certainly higher when there are psychosocial stressors in your life, if you're having a stressful kind of socioeconomic time. Any depressive episode usually peaks around six weeks, but can happen, the peaks are two to three months are having minor episodes. So actually if you did a point screening, doing a screening at like four months postpartum, you're going to get the highest total numbers. So it's not just in the first couple months. It's for really the whole first year it could happen.
And there are these risk factors, having your own history of depression, having alcohol or substance use, having forced social support, low income, or having an unplanned pregnancy. It happens to dads too. It's certainly helpful, though, to moms to have a dad who's not depressed. That can be protective buffering for the baby.
I'm going to skip this, but this is something you can look up. The still face experiment, it basically shows, some of you have seen it, we did this in our last training. Basically, this mom that stops reacting to her child, and you see how the child reacts when the mom no longer interacts. And you can see how they totally lose their ability to deal with the world because they just don't have that predictable back and forth. And so we know that it affects infants, it affects their attachment and their bonding, it affects language development because of that attachment and bonding and the joint attention that we talked about.
There are certainly risks for all these other kinds of things, developmental delays, injuries, failure to thrive. So we can screen as clinicians. It's good to screen at every well child visit in the first year.
And then once you screen, you need to know what to do. So what are the resources and supports out there? And then follow up closely.
You might want to bring them back sooner than their scheduled next visit to try to figure out what's going on. Some really key universal messages that are helpful are things to say that this Mother is not alone. It's not her fault. She's not to blame.
And with the right help, she can get better. Those are helpful messages. And then these are some resources. So Maternal Mental Health Now, previously the L.A.
County Perinatal Mental Health Task Force, has a wonderful resource directory. So you can find on their website a resource directory that you can search by types of therapies and by zip code. So if you know your client's patient's zip code and they're interested, say, It's searchable by insurance, so you know that you want to find somebody who has a master's degree who would see Medi-Cal in their zip code. You can try to find that.
Or support groups or different kinds of modalities. And then certainly, you said you were from Early Head Start. So Early Head Start, Head Start, the school district, there are wonderful mental health resources within the systems where you work as well.
Okay? You have all these slides in your packet, so it should be written down for you. And then how do we screen? We're going to go through these screening tools.
Rebecca's going to show you the Edinburgh postnatal depression scale and the PHQ-2 and 9. Okay? So...